direcció general de salut pública -...

Departament de SalutDirecció General de Salut Pública

Eurocare Bridging the Gap (BtG) Project:

Third meeting of networkBarcelona, 11th to 13th May 2006

Alcohol policy in CataloniaAntoni Plasència

Joan Colom Antoni GualLidia Segura



Alcohol Policy in Catalonia• Public Health in Spain and the reform of public

health services in Catalonia– Dr. Antoni Plasència- General Director of Public

Health• A public health approach to alcohol policy

– Dr. Joan Colom – Director of the Program on Substance Abuse

• The lessons learnt – Dr. Antoni Gual – Head of the Alcohol Unit of the

Government of Catalonia


3


PUBLIC HEALTH IN SPAINPUBLIC HEALTH IN SPAIN&&

THE REFORM OF THE REFORM OF PUBLIC HEALTH SERVICESPUBLIC HEALTH SERVICES

IN CATALONIAIN CATALONIA

Antoni PlasAntoni PlasèèncianciaDirector general de Salut PDirector general de Salut Púúblicablica

Eurocare Bridging the Gap (BtG). Barcelona, May 11-13, 2006


Introduction to the current situation of Public Health in Spainoutline of the basic components of the reform of PH services in CataloniaImplications for alcohol policiesand programs.

PurposePurpose


HealthHealth & social context (1)& social context (1)Aging society (lowest fertility rates & high life

expectancy)

Epidemiological profile: Cardiovascular, Cancer, Injuries, AIDS+drugsInequalities (social & geographical)North-East/South-West

Unbalanced trends in Health Objectives


Overall improvement in health trendsEmerging (global) health threatsEconomic impactIncreasing media interest and influenceIncreasing sense of vulnerability (individual and collective)Citizens’ growing request for information and empowerment

HealthHealth & social context (2)& social context (2)


HealthHealth systemsystem context (1)context (1)Restoration of democracy in 1977New constitutional structure: 17 Autonomous Regions

(Comunidades Autónomas)Quasi-federal model

Spain: 44 million pop.Catalonia: 7 million pop.


HealthHealth systemsystem context (2)context (2)

General Health Law, 1986Health care:

- free & universal, no explicit restrictions of access to most procedures - financed through taxes, centrally collected and redistributed (by capitation)- transferal of health responsibilities to the Regions (completed in 2002)- “split” between planning, financing and provision of services (mostly for Hospital & Primary care)


Public Health is generally not understood –maybe because when it is effective, nothing happens. Surgeon General Jocelyn Elders, 1995


PublicPublic healthhealth (*)(*)

People

NFP org.

Corporations AdministrationsHealth system

“ the organized effort of society to protect and promotehealth, and to prevent disease.”

PH policies

PH services

(*) ≠ publicly financed health care system

Public Health


protectionlaboratories

management of health authority

Surveillance and PH emergencyresponse

promotion and prevention

Health monitoring

Other (occupational health, foodsafety, etc.)

MainMain PH PH servicesservices


PublicPublic HealthHealth systemsystem in in SpainSpain: : organisationorganisationTransferralTransferral of PH of PH responsabilitiesresponsabilities to Regions in to Regions in latelate 7070’’ss

DevelopmentDevelopment of Regional PH of Regional PH structuresstructures ((heterogeneousheterogeneous):):-- surveillancesurveillance, , healthhealth protectionprotection, , healthhealth promotionpromotion

Concurrent Concurrent responsabilitiesresponsabilities withwith local local levellevel: : healthhealthprotectionprotection ((alsoalso healthhealth promotionpromotion in in largelarge urbanurban areasareas))

OverlapOverlap withwith somesome PrimaryPrimary CareCare functionsfunctions ((healthhealthpromotionpromotion, , diseasedisease preventionprevention))

OverlapOverlap withwith otherother organisationsorganisations: : environmentalenvironmental, , foodfood, etc., etc.

NationalNational MinistryMinistry of of HealthHealth: : regulatoryregulatory and and coordinatingcoordinating rolerole

VaryingVarying coordinationcoordination amongamong RegionsRegionsNationalNational ReferenceReference Agencies: Agencies: i.ei.e., Centro Nacional de ., Centro Nacional de

EpidemiologEpidemiologííaa, Agencia de , Agencia de SeguridadSeguridad AlimentariaAlimentaria

Departament de SalutDirecció General de Salut PúblicaDepartament de Salut

The Catalan Health System

Financing

Public Health Care Dependency

Planning

SYSTEMRes

earc

hTr

aini

ng

LAWS & REGULATIONS


FutureFuture PH PH servicesservices needneed to beto be• able to anticipate• able to solve• based on best available evidence (or on precautionary principle)• enforce the law• close to citizens and territories• transparent in comunication

• able to anticipate• able to solve• based on best available evidence (or on precautionary principle)• enforce the law• close to citizens and territories• transparent in comunication

Generate CCONFIDENCE AND SAFETY !ONFIDENCE AND SAFETY !


TheThe reformreform of of PublicPublic HealthHealth in in CataloniaCataloniaA

politicalpriority

(AcordsTinell)

Public Health(including occupational, environmental

health and food safety)

Public Health(including occupational, environmental

health and food safety)

PolicyBenefitsServices

promotion, prevention & protection, with the

support of surveillance, monitoring and research

promotion, prevention & protection, with the

support of surveillance, monitoring and research

An executive organizationoriented to the local level

Agency of Public Healthof Catalonia

“the point of access”

Agency of Public Healthof Catalonia

“the point of access”

With municipalitiesWith citizens

With professionals

Link with GTSCommunity Health

Management of transformation

Link with GTSCommunity Health

Management of transformation

A Public Health Law


SomeSome principlesprinciples ofof thethe PHS PHS reformreform in in CataloniaCatalonia (1)(1)

• Separate the regulatory and planning functions fromservice provision -> creation of the Public Health Agencyof Catalonia (ASPCAT)

• Implement an executive and interdepartmentalorganization

• Involve and coordinate PH local and regional resources• Promote coordination with health care• Orient the organization towards quality• Strengthen PH professional training (technical and

managerial levels) • Promote innovation and research linked with practice• Improve communication with the public and the media


Sector

GTS

Provision

Generalitat MunicipalitiesRegionalDirector PH

Hosp. S.mental Socio- PCare ESPsanit

PH teams (*)(multidisciplinary )

ESP

A decentralised Agency

connected with municipalities(Governs Territorials de Salut) and with local providers

(*) in collaboration

with municipalteams

A deconcentrated executiveAgency

Regional Agencies


ExecutiveExecutive rolerole and and continuitycontinuityCentral level

Local level

Exec

utiv

ero

leServices Services

PRO

TEC

TIO

NSU

RVE

ILLA

NC

E

Continuity and integrationPREVENTIONPROMOTION

audit role

Community health


Alcohol & Health: Global BalanceAlcohol & Health: Global Balance

• 10-15% hospital emergencies• 4% hospitalizations• 41,5% treatment demand XAD• 19.900 deaths (>6% annual mortality)

• 30-50% in fatal car injuries• 15-35% in severe car injuries• 17% in occupational injuries • 4.200 deaths by cirrhosis• 10,1 l. of alcohol consumption per capita


LinkingLinking alcohol alcohol policypolicy toto publicpublic healthhealth policypolicy• Launch the Catalan Public Health Agency, in charge of

– the design and implementation of programs incorporating effective strategies of health promotion & protection, and disease prevention, with the support of epidemiology, monitoring and research.

– providing support to policy formulation and planning– monitoring changes in key determinants and outcome indicators

• Development of a regional strategy on mental health promotion and mental disorder prevention in the framework of a global reorganisation of the public health policies and resources.

• Complement the medical approach with population-based public health interventions to address the broad dimensions of alcohol problems at the community level.


Public Health is generally not understood –maybe because when it is effective, nothing happens. Surgeon General Jocelyn Elders, 1995

The support of the population to public health ishigh... once it understands what it is about.

H. Taylor, 2002. The Future of Public Health


A A betterbetterorganizationorganization for a for a

betterbetter serviceservice

For more information:Reforma de la Salut Pública a la web del Departament de Salut:

http://www.gencat.net/salut/depsan/units/sanitat/html/ca/dir446/index.html




Departament de SalutDG Salut Pública. Òrgan Tècnic de Drogodependències.

Health DepartmentDG Public Health. Program on Substance Abuse

A public health approach to alcohol policy

Joan ColomDirector of the Program on Substance

Abuse



Index

• Alcohol as a health determinant: overcomingcultural barriers

• Alcohol in the Health Plan• Guidelines of the Program on Substance Abuse• The Catalan Network on Addictions (XAD)• From treatment to prevention:

– PHC: the Beveu Menys experience– School: ‘Salut i escola’ program

• Next steps: alcohol at work, road casualties, marketing control, etc.



0 200000 400000 600000 800000

Alcohol, 1996

Illegal Drugs,1997

Public Health Costs

Costs not related tohealth

Accidents

Other Departments

Legal Departments

Indirect Costs

Alcohol as a drug: overcomingcultural barriers

Sources: Portella et al., 1998García-Altés et al., 2000



Risky Drinking Prevalence

6

7

8

9

10

11

12

13

14

1999 2001 2003

15-29 years 15-65 years

Source: Household Survey on Drugs. Program on Substance Abuse



Health Plan 2002-2005Alcohol Chapter

• 3 general targets for health until 2010:– Reduce accidents related to alcohol– Reduce morbidity related to alcohol– Reduce prevalence of excessive alcohol

consumption among general population and specially among young people



• Integrated Mental Health Strategy to be launched in 2006. – To increase the commitment of the networks specializing

in health promotion and the prevention – Improve the competency and the capacity of PHC in the

treatment of people with mental health disorders and addictions

• Preparation of a Map of Health, Public Health and Social Services and an Integrated Governmental Plan for Caring for People with Mental Health Problems (IGPMH).

Director Plan on Mental Health and Addictions (DPMHA)



Guidelines of the Program on Substance Abuse

• Addictions are diseases and must be treated within the Health System

• The Drugs Plan must deal with all drugs, including alcohol and tobacco

• Drug and alcohol related problems must be viewed from a Public Health perspective




• Legislative activities• Prevention activities• Treatment of addictions. Creation of a network

of specialized centers (XAD)• Harm reduction activities• Introduction of alcohol related issues in Primary

Health Care.• Strategy to introduce programs of Drugs at Work



Legislative activities

• Two laws (20/85 and 10/91) have been developed by the Catalan Parliament concerning “substances that can produce addiction”.

• They are devoted to issues related with sales and availability of alcohol, establish age restrictions and legislate the limits of promotion and advertising



Prevention Activities

1. Health Education at school2. Leisure3. Specific groups4. Community5. Workplace



At school: preventive tools

“My friends, my garden”

(1993) 6-8 years

Tales that explain both personal conflicts and relationships problems that have to be sorted out.

“The adventure of life”(1999) 8-12 years

-To promote health habits and firm attitudes over consumption-To offer materials and training to students teachers and parents



At school: Preventive equipment

CD-Rom“Limit Zero”(1994) 14 -18 Relation between alcohol and car driving.

“And you, what do you think?” (1999) from 14Productive discussion about subjects as Living with the group, The free time, fashion and publicity, etc.

“Going out”(2001) from 17

Productive discussion about the “Going out”behaviour



Risk Reduction

• Monitoring scheme on new patterns of youth’s drug and alcohol use

• Consensus Commission for a “safer night”

• Programmes:– On site information– On site pill testing

Aims:

• Increase either contact and retention

• Decrease morbidity and mortality

• To give information about Harm and risk associated.

• Decrease either social exclusion and

social conflict




• Legislative activities• Prevention activities• Treatment of addictions. Creation of a

network of specialized centers (XAD)• Harm reduction activities• Introduction of alcohol related issues in Primary




Catalan Drug Addiction Network(Xad)

Specialised Resource Network for people with drug

addiction related problems.

• Public Health Care Network

• Health care to all Drug Addictions

• Wide distribution throughout Catalonia

• Free access



Catalan Drug Addiction Network(Xad)

INPATIENTUNITS: 11Beds: 53

OUTPATIENT UNITS

60

C.T.Units: 10

Dual Diagnosis Units2 Rehabilitation programs: 13

Directorate General of Substance Abuse and AIDS. Department of Health and Social Security.

Methadone Programs 72



Heroïna15%

Alcohol42%

Cocaïna25%

Cannabis4%

Altres4%

Tabac10%

Admissions to treatment- 2004

Font:Òrgan Tècnic de Drogodependències

N: 14.537



Harm Reduction Activities

• Guidelines on best practice

• Substitution treatment

• Syringe exchange and condom distribution

• Out-reach work and peer education

• Drop-in centres

• Drug users’ involvement





of specialized centers (XAD)• Harm reduction activities• Introduction of alcohol related issues in

Primary Health Care.• Strategy to introduce programs of Drugs at Work



Primary health care activities• Training courses for nurses and GPs• Setting goals for alcohol screening through the Health Plan • Establishing the Minimum Common Criteria for

intervention in alcohol related problems in Primary Health Care

• Testing of packages to screen and assess briefly risk drinkers

• “Beveu Menys”/Drink Less Program• Primary Health European Project on Alcohol (PHEPA

Project) funded by the European Commission• International Network on Brief Interventions of Alcohol

Problems



Customization of the training manual

Customization of theintervention package

Training thetrainers (n=84)

DISSEMINATION

347 PHC Centres7915 PHC professionals

Creation XaROHITERATION

Customization ofthe training manual

Training thetrainers (n=66)

Customization of theintervention package

2002

-200

520

05-2

008

The “Beveu Menys” Program



December 2005:• 84 trainers• 340 trainings• 98 % PHC centres• 7915 professionals• 900.000 € spent• Training packages:

– 8687 PHC – 109 trainers (XAD)

• Bulletins: 21

100%

90.2%

98.6%

100%

100%96.5%

100%

100%

What have we done?

Difusió segons RS

(anterior a l’actual reestructuració)



“Salut i Escola” Health & School Program• Open consultation at school of nurses from PHC

centres• Aimed at improving adolescents’ mental health

(eating disorders, anxiety disorders and depression) and addiction problems.

• A special circuit of collaboration among services has been designed and includes the mental health services

• A parallel evaluation process has been implemented and it is planned to extend the program to all the territory



Next steps• Full integration of the alcohol policy in the new Catalan Public Health

Agency and in the Mental Health Strategy• Improving the epidemiological surveillance on alcohol consumption and

alcohol problems• Better monitoring of the accomplishment of the regulations on alcohol

specially those related with selling, promotion and advertising• Continuation of the dissemination of EIBI in primary health care and

spreading the initiative to other health settings (hospitals, emergencies, etc.).

• Complete the dissemination of the Health and School program.• Development and promotion of workplace based prevention programs in

the framework of the agreement signed in march 2002. • Reduce alcohol-related traffic casualties • Working towards the development of a national, multisectorial and

comprehensive alcohol policy



The lessons learnt

Antoni Gual1,2 & Lidia Segura2

1. Alcohol Unit, Neurosciences Institute. Hospital Clínic. Barcelona

2. Program on Substance Abuse. Public Health Gen. Dir.. Health Dep. Catalonia.



Index• A regional/national perspective

– The Beveu Menys evaluation– The Xaroh

• A European perspective– The Phepa 1 evaluation– The Phepa 2 Project – The Inebria experience



The “Beveu Menys” evaluation



Acceptance of the Course

• Rate of Attendance high and maintained during all sessions

• 83% of participants attended at least 80% of the sessions.

02468

101214161820

1 2 3 4 5

Sessions

83%

17%

Accreditation

Certification



What's the impact of training ontrainers?*

Strongly disagree -/+

Strongly agree

To train PHC teams in alcohol is important 0 2 0 2 4 29 63To train PHC professionals pays off 6 6 10 18 20 24 14

Coordination between PHC and specialists is impossible 47 39 4 8 2 0 0

* Results are shown in percentages. N=49



Drink Less Evaluation ++ + +/- - --

Global evaluation 15 68,3 16,7 0 0

Useful to give advice 10 40 41,7 8,3 0

Increase skills 10,2 40,7 42,4 6,8 0

Helps in daily clinical work 6,8 69,5 10,2 13,6 0

Helps to screen 8,1 31,7 43,3 16,7 0

• Results are shown in percentages (N=63)

• Attended 94% of professionals interviewed



Changes in Professionals at 3 monthsBasal Folow-up Analysis

N % N % pWomen 55 68,8 41 61,2 n.s.

I have enough training 47 58,8 41 61,2 n.s.SDU contents in grams 43 57,3 49 87,5 p<0.001

% Patients screened (x;sd) 46,71 32 21,60 25,4 p<0.001% Risky drinking/day (x;sd) 3.93 4.80 5,14 6,8 n.s% AD /day (x;sd) 1,17 1,6 2,32 4,42 n.s

I’m satisfied to help to change alcohol habits

50 62,5 50 84,7 p<0.05

Risky Drinking Criteria 39 51.3 36 63,2 n.s.Use of standardized instruments 6 7,9 24 42,1 p<0.01



Medical Records: ResultsBasal Folow-up Analysis

N % N % pWomen 488 57,5 452 55,9 n.s

Age (X, SD) 54.85 19.60 52,52 21,56 n.s.Screened last 3 Months 75 8.8 74 9.2 n.s.

Shared treatment 1 1,6 1 2 n.s.

MR opened (X, SD) 7.35 4.94 7.51 5.39 n.s.

Risky Drinking 2 3,2 3 4,6 n.s.Alcohol Dependent 3 4,8 1 1,6 n.s.



Patients ResultsBasal Folow-up Analysis

N % N % p

Women 620 64,1 627 61,5 n.s.

Age (Mean and SD) 52,8 18,6 54,6 19 n.s

Once a month 322 33,6 362 35,6 n.s

Risky drinkers 185 19,3 180 18,7 n.s.

Primary Studies 640 67 685 67,8 n.s.

Working 432 44,7 410 39,9 p<0.03

Never Screened 493 51,1 542 53,4 n.s



What's the impact of training on HealthProfessionals: increase of referrals

3000

4000

5000

6000

7000

8000

1998

1999

2000

2001

2002

2003

1000

2000

3000

4000

1998 1999 2000 2001 2002 2003

Referrals to the network of specialized centres

AlcoholOther drugs

Alcohol referralsPHCOther sources



The process evaluationFocus groups: strengths

TRAINERS & PHC DIRECTORS• Facilitation of the contact and approach between

Drug Addiction Network and PHC• Good acceptance of the courses by the PH

professionals, specially nurses• High interest on motivational approach by PHC• Referral rates for alcohol dependence to

specialized centres a marked increase • Demand of continuity strategies



The process evaluationFocus groups: weaknesses

TRAINERS & PHC DIRECTORS• Lack of time of the PHC professionals: priority is

given to treatment vs preventive interventions• No agreement on the implementation level • Lack of facilities for the implementation: Medical

Record, contractual goals• Lack of contractual agreement related to the

intervention



What have we learnt from the initialexperience?

• Alcohol poses a difficult challenge to the HealthSystem.

• The change will not appear dramatically. Slow changesare to be expected if continuous work is done. The firstmovement in PHC appears with the most severe cases.

• Implementation should be reinforced throughcontractual incentives

• Future developments should enhance the nurses role, and promote a more active implication of PHC workers

• More resources should be allocated to the wholesystem.



The “Beveu Menys” Implementation

As an iterative processCreation of the PHC network (XaROH)Creation of the Alcohol and Primary Health Group (GAAP) Creation of the Nursing working group.CME strategies



Next stepsIntroduction of an Alcohol Screening Indicatorin the Health System Contract.Adaptation of the BM tools for the existing computerized medical records in PHC settingsInclusion of the preventive work on alcohol consumption in the professionals' personal contract goalsDissemination of SBI techniques to other settings (hospitals, emergency rooms, etc.).Settlement of relations with Latin America.



A European perspective

– The Phepa 1 evaluation– The Phepa 2 Project – The Inebria experience



PHEPA– European recommendations and clinical guidelines

for health care purchasers and providers

– European training program for primary health care professionals

– Comprehensive Internet site database on good practice, providing the evidence base in the domains of efficacy, economics, health and policy

– Series of country specific dissemination experiences and strategies.

PHEPA



What have we done?• Products have been finished• Four international meetings were hold • Country Based Teams have been settled

and implementation strategies have been prepared

• PHEPA II approved by the EC for co-financing expanding the work to 24 countries

PHEPA



Clinical Guidelines SummaryI. IntroductionII. Methods to prepare the guidelinesIII. Describing alcohol consumption and alcohol related harmIV. Alcohol and healthV. Identifying hazardous and harmful alcohol consumption VI. Effectiveness of brief interventionsVII. Cost and cost effectiveness of brief interventionsVIII. Implementing identification and brief intervention

programmesIX. Assessing the harm done by alcohol and alcohol dependenceAnnexeAcknowledgements

Available on-line at: www.phepa.net



Training Programme1 Introduction and basic concepts

2 Early identification

3 Brief Intervention I

4 Brief Intervention II

5 Alcohol Dependence

6 Implementation of the EIBI Alcohol Programme

Available on-line at: www.phepa.net



Phepa.net



Implementation in countriesAssessment tool

Creation of working groups at a national level

Design of a country based national strategy



Evaluation

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Enhanced ability to affectpublic policy

Development of valuablerelationship

Ability to have a greater impactthan I could have on my ow n

Acquisition of additionalf inancial support

Most important Extremely important Very importantSomewhat important Not important

Please rate the advantages of participating in this project

PHEPA



Evaluation: General Overview

0%10%20%30%40%50%60%70%80%90%

100%

The project was allworth it?

I will join such aproject again

Absolutely disagree

Somewhat disagree

Uncertain

Somewhat agree

Absolutely agree

PHEPA



Evaluation: General OverviewBenefits and costs

0 %

10 %

2 0 %

3 0 %

4 0 %

5 0 %

6 0 %

7 0 %

8 0 %

9 0 %

10 0 %

Much more disadvantagesthan advantagesMore disadvantages thanadvantagesBoth are equal

More advantages thandisadvantagesMuch more advantages thandisadvantages

How do the advantages compare to the disadvantagesof participating in this project?

PHEPA



Evaluation: Members satisfaction

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

The way people in the group work together

The general way in which the project wasdeveloped

The progress of the group since thebeginning of the project

Completely satisfied Mostly satisfied Somewhat satisfied

A little satisfied Not at all satisfied

PHEPA



0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Clinical Guidelines

Training Manual

Internet website & database

National dissemination strategy

Excellent Good Fair Bad Very bad

Your opinion on the achievement of the products?

PHEPA



‘PHEPA Project on disseminating brief interventions on alcohol problems Europe wide’

• The general objective of the present project is:– to build on the experience and products of

PHEPA I– to promote the dissemination of best practice

on early identification and brief interventions on alcohol problems within the general population.

PHEPA



Catalonia

BelgiumBulgariaCzech RepublicEnglandEstoniaDenmarkFinlandFranceGermanyGreeceHungaryIrelandItalyLithuaniaLatviaNetherlandsPoland

B

P I GrS

D

SlF

UKIr

F

Sw

PlG

N

B

HCz

PolandPortugalRomaniaSloveniaSlovak RepublikSpain SwedenTurqueyEUROPREV

Partners of the Phepa II Project•24 associated partners•10 collaborating partners (6 countries and EUROPREV)

PHEPA



Phepa II. Specific objectives• To create a sustained European Platform of health

professionals and brief interventions• To develop an assessment tool and a registry to assess and

document the current status of services for brief interventions• To build an Internet based resource centre for health

professionals, policy makers and providers, on brief interventions;

• To roll out a training programme throughout Member States to harmonize the skills of European health professionals

• To roll out clinical guidelines throughout Member States toharmonize the quality of brief interventions.

PHEPA



Conclusions1. Alcohol is a main public health problem that

contributes enormously to the workload of PHC professionals

2. European PHC professionals still lack training and clear guidelines on how to intervene in alcohol related problems, ranging from risky drinking to severe dependence

3. There’s a need for homogenisation of intervention criteria at a European level.

PHEPA



Conclusions3. There’s a need for homogenisation of

intervention criteria at a European level. The PHEPA project contributes to this homogenisation by producing and rolling out European clinical guidelines on alcohol, a training programme for PHC, a web site on good clinical practice and a series of country based strategies.

PHEPA



International Network on Brief Interventions for Alcohol Problems [INEBRIA]

3rd International Conference of INEBRIALisbon, 26th – 28th October 2006

WHO

Organization: The conference will be hosted by Dr. Maria Joao Heitor dos Santos and Dr. Cristina Ribeiro, General Directorate of Health – Lisbon (Portugal) and will be organized with the support of WHO and the Department of Health of the Government of Catalonia, that holds the Inebria Secretariat.

Speakers: include Peter Anderson, Tom Babor, Cheryl Cherpitel, Joan Colom, Antoni Gual, Nick Heather, Isidore Obot, and Kaija Seppä.

More details of the conference at www.inebria.net



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